Shatin D, Levin R, Ireys H T, Haller V
Center for Health Care Policy and Evaluation, United HealthCare, Minneapolis, Minnesota, USA.
Pediatrics. 1998 Oct;102(4):E44. doi: 10.1542/peds.102.4.e44.
This study compared utilization of health care services by children with chronic conditions who were insured by either Medicaid or an employer group in 1992 and 1993. Five chronic conditions were selected to illustrate patterns of service use: asthma, attention deficit disorder, diabetes, epilepsy, and sickle cell anemia.
Administrative databases were used to develop estimates of health services utilization for children <18 years of age with the five selected conditions, who had been enrolled for at least 6 continuous months. All claims for a child identified with one of these five conditions were included in the analysis, including claims for diagnoses and procedures not directly related to the primary diagnosis. Estimates were derived for eight services (eg, hospital admissions, emergency department (ED), home health). Data were used from two Independent Practice Association model health plans in two states. Differences across the states were controlled by selecting one Medicaid and one employer-insured program from each of the two plans in both states. Regional variation was controlled for because both health plans were located in one geographical region. In each case, physicians were paid on a fee-for-service basis, with generally open access to specialists rather than primary care gatekeeper models of delivery: t tests were used to compare service use rates between Medicaid and employer-insured populations.
A total of 8668 children across all health plan groups had at least one of the selected conditions. Because Medicaid enrolled-children tended to be younger, analyses were adjusted for age. In both systems, a greater percentage of Medicaid children had these five study conditions (5%) compared with employer-insured children (3%), suggesting that the Medicaid population was sicker. Mean length of enrollment during the 2-year study was longer for children in employer-insured programs. Children with chronic conditions enrolled in Medicaid managed care generally used services at a higher rate compared with children with similar conditions enrolled in employer-insured managed care. The extent of the increased use varied by condition, by service type, and by plan. Children with any of the chronic conditions studied had from 2 to almost 5 times more ED visits if they were enrolled in Medicaid than if they were enrolled in employer-based managed care, depending on the specific condition. In one of the two plans, Medicaid-enrolled children had more outpatient services, laboratory services, and radiography services than their counterparts in employer-based managed care. The same pattern of use was found for home health services (except for children with diabetes) and for office visits (except for children with sickle cell). The results show higher use of all services by children with asthma and diabetes in Medicaid managed care compared with employer-based managed care. In contrast, the pattern is mixed for children with epilepsy and sickle cell. The sample size of children with these conditions was smaller than with the three other conditions, which may account, in part, for a varied pattern of results. The pattern of use for attention deficit hyperactivity disorder (ADHD) was generally different from the other conditions. Children with ADHD in employer-based managed care had more hospital admissions, hospital days, and office visits than their counterparts in Medicaid managed care. In contrast, Medicaid-enrolled children with ADHD had more ED visits, laboratory services, outpatient hospital visits, and radiography services. Other than ED visits, the differences in service use between Medicaid and employer-insured children with ADHD were minimal. Of note, the pattern for ADHD is the same for most services for Plans A and B (excluding home health visits). This utilization pattern may reflect service use for comorbid conditions. Part of this difference may be explained by differences in Medicaid e
本研究比较了1992年和1993年由医疗补助计划或雇主团体承保的慢性病儿童的医疗服务利用情况。选择了五种慢性病来说明服务使用模式：哮喘、注意力缺陷障碍、糖尿病、癫痫和镰状细胞贫血。
利用行政数据库对18岁以下患有上述五种选定疾病且连续参保至少6个月的儿童的医疗服务利用情况进行估计。对确定患有这五种疾病之一的儿童的所有索赔进行分析，包括与主要诊断无直接关系的诊断和程序的索赔。得出了八项服务的估计数（如住院、急诊科就诊、家庭健康服务）。数据来自两个州的两个独立执业协会模式的健康计划。通过从两个州的两个计划中各选择一个医疗补助计划和一个雇主承保计划来控制各州之间的差异。由于两个健康计划都位于一个地理区域，因此对区域差异进行了控制。在每种情况下，医生按服务收费，通常可以直接看专科医生，而不是采用初级保健守门人模式：使用t检验比较医疗补助计划参保人群和雇主承保人群的服务使用率。
所有健康计划组中共有8668名儿童至少患有上述选定疾病之一。由于参加医疗补助计划的儿童往往年龄较小，因此对分析进行了年龄调整。在两个系统中，患有这五种研究疾病的医疗补助计划儿童的比例（5%）高于雇主承保儿童（3%），这表明医疗补助计划人群病情更严重。在为期两年的研究中，雇主承保计划中的儿童的平均参保时长更长。参加医疗补助计划管理式医疗的慢性病儿童与参加雇主承保管理式医疗的类似疾病儿童相比，通常使用服务的频率更高。使用增加的程度因疾病、服务类型和计划而异。患有任何一种所研究慢性病的儿童，如果参加医疗补助计划，其急诊科就诊次数比参加雇主管理式医疗的儿童多2至近5倍，具体取决于特定疾病。在两个计划中的一个计划中，参加医疗补助计划的儿童比参加雇主管理式医疗的儿童有更多的门诊服务、实验室服务和放射检查服务。家庭健康服务（糖尿病儿童除外）和门诊就诊（镰状细胞贫血儿童除外）也发现了相同的使用模式。结果显示，与雇主管理式医疗相比，医疗补助计划管理式医疗中患有哮喘和糖尿病的儿童对所有服务的使用更多。相比之下，癫痫和镰状细胞贫血儿童的模式则各不相同。患有这些疾病的儿童样本量比其他三种疾病的儿童小，这可能部分解释了结果模式的差异。注意力缺陷多动障碍（ADHD）的使用模式通常与其他疾病不同。参加雇主管理式医疗的ADHD儿童比参加医疗补助计划管理式医疗的儿童有更多的住院、住院天数和门诊就诊。相比之下，参加医疗补助计划的ADHD儿童有更多的急诊科就诊、实验室服务、门诊住院就诊和放射检查服务。除了急诊科就诊外，医疗补助计划参保儿童和雇主承保ADHD儿童在服务使用上的差异很小。值得注意的是，计划A和B（不包括家庭健康就诊）的大多数服务中ADHD的模式是相同的。这种使用模式可能反映了合并症的服务使用情况。这种差异的部分原因可能是医疗补助计划中的差异。
